DH Cardiac Rehabilitation Commissioning Pack: highlights and process. Prof Patrick Doherty BACR conference Liverpool 2010

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1 DH Cardiac Rehabilitation Commissioning Pack: highlights and process Prof Patrick Doherty BACR conference Liverpool 2010

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3 CR commissioning pack working groups: led by SCDU and NHS Improvement 1. A reference group including leaders from rehabilitation, cardiology and GPs that helped design the service specification Six meetings to develop the clinical service specification The first draft shared with clinicians & commissioners in May 2010 The reference group signed off the pack specification July Pricing and economic team (pricing tool) Support from the DH pricing team and health economists Case for change and pricing tool 3. Contracting and procurement team Legal aspects of contracting Quality assurance in commissioning best practice This was a collaborative approach that involved the DH, SCDU, NHS Improvement, PbR, NHS IC, BACR, NACR and the BHF

4 Scope of the CR pack: patients High priority shall be given to the primary diagnosis of: 1. Acute coronary syndrome (ACS) which includes STEMI, NSTEMI and unstable angina (NICE Guidance CG 48 and CG 94) a. Should include all patients undergoing reperfusion (e.g. CABG, PCI or PPCI) 2. Chronic heart failure of new diagnosis or chronic heart failure with a step change in clinical presentation of (NICE Guidance CG 108) The costing model for the cardiac rehabilitation commissioning pack is based on the high priority inclusion.

5 As cardiac rehabilitation services develop and are successful with high priority inclusion then CR services should be extended to include: 3. Heart transplant patients and patients with ventricular assist devices (VADs) 4. Patients that have undergone surgery for implantable cardioverter defibrillator (ICD) or Cardiac resynchronisation therapy (CRT) for reasons other than ACS or heart failure 5. Heart valve replacement patients for reasons other than ACS or heart failure 6. Patients with a confirmed diagnosis of exertional angina A full list of codes covering the above patient groups can be found at Annex 1. Providers shall include other conditions where there is a clear clinical basis and benefit for referral to cardiac rehabilitation. This situation can exist where the numbers of patients is generally too small to produce rigorous evidence but the perceived benefits are obvious. An example could be certain adult patients with congenital heart conditions.

6 Cardiac Rehabilitation Pathway (all stages)

7 Stage 1 Manage Referral and Recruit Patient to Cardiac Rehabilitation Programme

8 Stage 2 Assess Patient for Cardiac Rehabilitation

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10 Core components for cardiac rehabilitation

11 The Provider shall offer choice and inform the patient of the types of cardiac rehabilitation interventions and locations of those interventions offered by the service and agree with the patient whether the patient is ready and willing to commence all relevant aspects of the programme of cardiac rehabilitation in accordance with the Care Plan developed in Stage 3. PATIENT NEEDS Care Plan Lifestyle Core components Risk factor management Cardio protective drug therapy & devices Due to the behavioural and self motivational emphasis of cardiac rehabilitation the evidence supports patient preference as important and suggests that patients benefit the most if they pursue a programme they feel works for them. No single approach can accommodate the range of patient preferences; therefore the Provider shall offer a range of evidence based approaches and venues at times that suit patient choice. Psychosocial wellbeing Education Long-term management EVIDENCE BASED APPROACHES PATIENT PREFERENCES

12 Stage 3 Develop Patient Care Plan

13 Stage 4 Deliver comprehensive cardiac rehabilitation

14 Stage 5 Conduct final assessment

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16 Cardiac Rehabilitation Pathway (all stages)

17 Major differences to what exists There are no phases No set time frames for patients but it is priced on a 20 sessions basis ( including 16 sessions for delivery of core components) Successful CR is based more on patient outcome than process completion Some process and productivity measures are included that are deemed relevant to service provision Linked to primary care services where relevant to avoid replication of provision

18 CR pack cost analysis Summary Costing Staff Costing Existing Cardiac Cost Pathway Elements X = Total Loaded staff costs + Initial Costs Commissioner specific costs = Acute initial Admissions cost + Current CR Cost = Acute initial Admissions cost + Estimated CR Cost + + (Spread over the contract life) Acute cost of Readmissions Vs New Cardiac Service Cost (based on higher volume) + Acute cost of Readmissions (based on lower volume) If the New Cardiac Service Cost is lower than the Existing Cardiac Cost this would indicate a net financial benefit of commissioning the Cardiac Rehab Pathway. The cost benefit is made up of a the following tabs; HES Readmission Calculation - This defines how the readmissions were calculated for the following tabs Cost Benefit Assumptions - This defines the assumptions being made, some commissioner input is required PCT Consortium - This allows you so select several PCT's to group up your activity PCT Pathway Summary - This shows the difference between costs for existing cardiac care programme and after the implementation of the proposed CR pathway at single patient level PCT Financial Summary - This shows the financial impact of implementing the pack in total financial terms Several Analysis Graphs to show the Selected PCT's relative position when compared with all PCTs

19 Key indicators for the CR service Uptake Completion Readmissions (where appropriate) Patient satisfaction NACR is recommended as the mechanism for data collection

20 Outcome measures for patients Aim is to measure baseline trends to inform patient agreed goals and then assess the extent of change between baseline and post rehabilitation in respect of relevant outcomes. For each patient these could include: Psychological well being (HADs) Functional capacity (fitness) SWT, SMWT etc BMI measures for all and waist circumference measures for patients with a BMI <35 kg/m2 (CG 43) Quality of Life (Dartmouth or MLWHF) Smoking cessation Compliance with medication Compliance with healthy eating plan NACR is recommended as the mechanism for data collection

21 Next steps GP commissioner online testing completed on 1st Oct Survey information collated and alterations to contracting and procurement made CR pack will be set up on the DH website on the 15th October Launch last week in October NHS Improvement commissioning priority projects commence on the 4th November 2010

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24 Conclusion The DH, SCDU, NHS Improvement, BACR, NACR and BHF are all committed to this new joined up initiative The case for change and evidence base is very strong and makes a compelling case to commissioners The cost analysis has already made a significant contribution to enabling providers to engage in service redesign and procurement 2010/11 will see the roll out of the packs and a strengthening of CR NHS Improvement looks forward to next year s conference were we hope to share the success of a new wave of innovative CR programmes

25 NHS Improvement: Thank You! See the NHS Improvement stand for more information.